A look at the facts: can large-scale general practice deliver?

In July, NHS England published details of the 'Multispecialty Community Provider (MCP) emerging care model and contract framework' ahead of a first draft of the MCP contract, which is due this month. The framework sets out how accountable providers of community-based services – that is, organisations that will take on the financial responsibility for meeting the needs of whole populations for all services, including primary medical services – are anticipated to emerge in England.

The report sets out the contribution of general practice to the MCPs: “no system of accountable care will get off the ground and be viable without the inclusion and active support of general practice”. It goes on to state that “general practice at scale is a natural first step towards an MCP”. It seems clear that NHS England considers collaboration between individual general practices to be a necessary stepping stone towards achieving the new care models set out in the Five Year Forward View.

Large-scale general practice

However, the MCP framework is only the latest in a series of policy documents, reports and forms of support – initially from GP-led organisations and health think tanks, but increasingly now from NHS England – that propose working at scale as a way to address some of the challenges general practice faces.

Underpinning this momentum are expectations that large-scale general practice collaboration can deliver on a wide range of ambitious objectives. These include being better placed to: innovate with and strengthen the primary care workforce; increase access and extend the range of services available through practices; improve clinical quality of care and reduce unwarranted variation in service delivery; and (perhaps the most frequently discussed) create efficiencies and economies of scale in order to make general practice more financially sustainable.

A survey undertaken by the Nuffield Trust and the Royal College of General Practitioners in 2015 confirmed that GPs are indeed scaling up, with 73 per cent of GP respondents stating they were part of a large-scale collaboration.

A look at the evidence

The Nuffield Trust's recently published study, Is bigger better? Lessons for large-scale general practice, goes some way to helping answer the question of whether large-scale general practice is likely to be able to deliver what is expected of it. Building on this, our new report, Large-scale general practice in England: What can we learn from the literature?, examines other evidence on the impact of new forms of large-scale general practice collaborations in England and also explores studies of other organisational developments that have similarities, such as clinical networks, integrated care initiatives, out-of-hours cooperatives and GP-led commissioning. The report provides added insight into how large-scale collaborations evolve, how this evolution may affect their likelihood of success, and (perhaps most importantly) just how realistic current expectations of what large-scale general practice can achieve might be.

Taken together, these two reports highlight that large-scale general practice may be well placed to achieve some of the expectations placed upon it. However, the evidence base is still very limited, and virtually non-existent in important areas – in particular the impact on costs and patient experience.

So what do we know?

There is potential to improve performance

Evidence from eight managed general practice networks in the London Borough of Tower Hamlets found that networks may have some key enabling functions that can help drive improvements in care. In targeted clinical areas, such as immunisation or diabetes, proactive care planning and screening targets improved, as did a variety of health outcomes. The studies suggest that the networks had features that helped to drive improvements, including standardised data collection, shared IT systems, peer-review dashboards, shared network managers and financial incentives at network rather than practice level, which encouraged collaboration to achieve targets.

A study of a large multi-site GP practice organisation in England suggests that this type of model may be well placed to improve safety and quality processes through standardisation of incident reporting, increased learning between practices, and enhanced training and support. The organisation used surveys of patients and 'mystery shoppers' to monitor performance, and performance indicators were benchmarked in order to stimulate competition between practices to achieve performance targets.

Potential challenges and unintended consequences

However, the evidence also points to pitfalls that are likely to be encountered in trying to scale up general practice. Achieving meaningful patient and public involvement in planning and implementation of changes to the organisation of health services has proved consistently challenging. Without this, there is a risk that reorganisations of health services do not address patient needs. Furthermore, the literature does not point towards consistent or marked improvements in patient experience as a result of scaling up or integration. For example, while patients may value greater coordination of care, the evidence indicates that changes in routes of access, even if they increase opportunities to access care, may not always be well received by patients.

Likewise, while the large-scale multi-site GP practice organisation described above led to improvements in some areas, there were also unintended consequences affecting workforce turnover and continuity of care.

Pros and cons of mandated versus voluntary collaborations

The current MCP framework clearly states that the participation of general practices will be voluntary and that there will be three different ways to form an MCP. However, the framework makes it clear that although they are “more radical and furthest away from the status quo”, fully integrated MCPs that hold a single contract for all primary medical and community services for a whole population are the preferred direction of travel. This would entail much larger, higher-value service contracts than general practice partnerships have held to date and would be likely to require a move towards large-scale organisations within which GP practices would sit.

Voluntary collaborations between GP practices can emerge for different reasons, subject to the local context. By their nature they are heterogeneous, and may not always be inclusive. The evidence suggests that this may result in inequities and complexity in organisational form. On the other hand, if collaborations between GP practices are mandated, this may make their activities more legitimate, provide a framework for new relationships and may result in more inclusive collaborations. However, this may come at the cost of stifling innovation and disengaging clinicians, or worse, being met with major resistance from GPs.

Crucial ingredients for collaboration

The degree of GP engagement, quality of clinical leadership, as well as pre-existing relationships within the local health economy can make or break new collaborations. Importantly, the time and resources needed to establish large-scale networks or new organisations are often underestimated, and expectations do not always materialise.

Time to take stock?

In light of the evidence, before pressing ahead with scaling up general practice in order to create fully integrated MCPs, it is particularly important to take stock of what previous experience tells us, and to learn from this. If the risks and challenges of moving general practice to scale are overlooked, the ambitions now set out by NHS England could be severely undermined.